“This
is tragedy. This is misery. This is all kinds of pain, for families,
for friends, for loved ones.”

“Good epidemiology is of paramount importance to our work and I’m so
grateful for the work that epidemiologists do.”

Robert Pack

[Editor: Last month President Trump
declared the opioid drug problem a national emergency and called for
an all out effort to defeat this ongoing epidemic. To obtain a deeper
understanding of the magnitude and causes of the problem, The
Epidemiology Monitor interviewed Robert Pack, Associate Dean
for Academic Affairs & Professor of Community and Behavioral Health at
the East Tennessee State University (ETSU) College of Public Health.
Dr Pack is chair of the Prescription Drug Abuse/Misuse Working Group
at ETSU, Executive Director of the ETSU Center for Prescription Drug
Abuse and Treatment and PI of an NIDA-funded five year research
infrastructure grant that includes three research projects. The
interview which follows makes compelling reading and provides
epidemiologists with an in-depth understanding of the current crisis
and how epidemiologists might further contribute to addressing the
problem.]

EM: The President recently
declared the opioid crisis a national public health emergency stating
that 175 persons die each day from drug overdoses. What do you think
best conveys the magnitude of the crisis?

Pack:
Most commuter jets, such as those that take many of us from our
hometowns to central air travel hubs, hold between 70-100 passengers.
Would Americans be OK with losing one or two commuter jets full of
people each day? Absolutely not. Airlines would be grounded and all
hands would be on deck to identify the problem, the very best
engineers would be brought in to fix the problem and no resources
would be spared. Stricter safety policies would be enacted, and
checklists made and completed at a scale heretofore unimaginable. We
simply would not allow the industry to continue. The conditions that
allowed such a tragic scale of events would be fundamentally altered
and the problem would be corrected, such that air travel became safe
again. This is the type of national level commitment that we need to
address the opioid problem.

EM:
The President compared the problem of drug overdoses to gun homicides
and motor vehicle deaths. Help us to understand the toll being
exacted by opioid drugs.

Pack:
Unintentional poisonings, a category that includes overdose deaths, is
the overall leading cause of injury death. It surpassed motor vehicle
accidents, falls, suicides and homicides in the US several years ago.
But the problem does not lie just in the numbers, though they are
tragic. It lies in the suffering of the family grieving for a son
lost to overdose, or a daughter numbed for years by substance abuse,
or the son or daughter that is confused and has no words to express
the grief of losing their mom. It lies in the stigma and shame of the
broken relationships and trust that substance use disorder causes.
Suicide is similar in that it is shrouded by value judgements and
whispers. We can speak objectively about motor vehicle accidents and
even homicides, to a large extent. Until we can begin processing
overdose and suicide objectively, and acknowledge the scale of the
public health problem that we are facing, we will continue to accept
fragmented, short-term solutions to the problem.

EM:
What are the projections for the impact of this epidemic if current
trends continue?

Pack:Dr. Don Burke, Dean of the University of Pittsburgh Graduate
School of Public Health, leads a team of epidemiologists that has
demonstrated that drug poisoning deaths have increased exponentially,
far outpacing population growth, since at least 1979. The exponential
curve is striking when you see it, but is even more so when you see
that, when transformed by logarithmic function it plots with an R^2 of
.99, i.e., that the next several years of the epidemic can be plotted
with 99% accuracy. They showed that the number increases about 9%
each year, with a doubling rate of every eight years. They have shown
that it took about 15 years for our country to experience 300,000
overdose deaths, but that we will experience 300,000 more in the next
five years unless we do something dramatically different. His team
has made similar plots for the data in each state, and for most major
cities. There are only a few examples of places that do not fit the
same trend.

EM:
The report from the Presidential Commission states that prescription
opioids now affect a wide age range, both well-off and financially
disadvantaged families, urban and rural populations, and all ethnic
and racial groups. What should epidemiologists understand about the
epidemiology of the opioid crisis?

Pack:
The short answer is that it is complex and changing. The overdose
epidemic used to be one of older people and is now clearly moving into
a younger demographic. I have seen some bimodal plots of this wherein
there are peaks currently emerging in the later 20s and the middle
40s. Plots that break that data down over time show a transition from
mid 40s to this bimodal shape.

The recent MMWR article that elaborated upon the
distinctions between the epidemic in rural vs urban areas, as well as
some of our team’s own work, has shown that the epidemic is very
different along the urban-rural continuum. Prescription drug abuse
has been a more (but by no means exclusively) rural phenomenon, and
heroin/fentanyl abuse more urban.

EM:
How does risk perception influence the opioid crisis?

Pack:
When many of us were young, our perception of risk about heroin was
that it was extremely risky to even try it, and in most cases that
perception, and a general lack of availability, at least when we were
young, was likely protective.

From
the Monitoring the Future data, which is specific to youth (taken from
a random sample of high school students each year) we know that for
some drugs, like marijuana, risk perception and use are negatively
correlated. For the most part, opioid use disorder has historically
been a condition of older users that graduated to opioids after other
drugs in their teens. Because of this, the same annual cross
sectional data for opioid use disorder and risk perception are less
clear mostly because the numbers were historically so small for high
school student use of heroin (the survey did not ask about prescribed
opioids until a few years ago). But I believe that a lot of people
slipped into this condition because the risk perception of prescribed
opioids was so low for so long. The risk perception for heroin use
was likely very high, but for prescribed opioids, quite low. I think
people went over the ‘risk threshold’ into heroin when it became known
that heroin was more cheaply and readily available to satisfy the
craving for opiates.

EM:
What are the main drivers of the overdose problem?

Pack:
The current overdose problem is a result of several different drivers,
a few of which I will describe here. First, there has been
tremendous growth in the amount of prescribed and dispensed milligrams
of morphine equivalent (MME; a standardized unit of measurement for
opioids of different strength) which started in the late 1990’s and
has grown into a large scale of individuals that are physically
dependent on opioids. Beginning around 2010, the medical and policy
community began to see the risks of over-prescribing and subsequently
clamped down both on over-prescribing and the phenomenon that became
known as doctor-shopping, or individuals going to several different
prescribers to get prescriptions for opioids, for consumption or
sale. I believe this contributed to a larger demand for illicitly
traded opioids, including heroin. Fentanyl is, I am told, easily
synthesized and trafficked from China and Mexico to sites in Canada
and the US, and then cut into both heroin and other street drugs,
including counterfeit prescription drugs. Fentanyl-laced heroin is
largely responsible for the current spate of overdose deaths. The
2017 National Drug Threat Assessment from the Drug Enforcement
Administration is very informative on this topic.

EM: Can you describe how you see risk perception changing?

Pack: I believe that, at
some point, there will be a large enough awareness about the topic,
that it is going to cause people to fear the outcome of a drug
overdose and we will begin to see population level declines in the initiation of opioid
misuse. I believe this will cause a slowing in the rate of new people
with opioid use disorder, over a long period of time. However, there
are a lot of people with opioid use disorder already, and some with
massive tolerance for opioids. Depending on how long and how severe
their disorder many will not have volitional control over their
behavior and won’t follow rational decision making processes that you
may expect from most. A large number of them are immersed in this new
reality of their supply being more deadly than ever. Hence, between
now and then (when the population level perception of risk is
extremely high and new initiates to opioids have greatly decreased)
there will be a lot of misery.

EM:
What other drivers are you aware of?

Pack:
There are other drivers of this problem, to be sure. For example, a
lot of money has been made by profiteering all along the legitimate
supply-side, such as by pharmaceutical companies, poorly run pain
clinics, overprescribing physicians (both willing and unwitting), and
even by some people in the business of treating those with opioid use
disorder such as with medication-assisted treatment or in-patient
treatment. However, these are difficult things to prove and our team
is trying to stay focused on the larger picture, which is that a lot
of people are suffering and need help urgently and that excellent
primary prevention programs need to be put into place quickly.

EM:
You have said in another venue that we need to think about the opioid
problem as a “chronic relapsing disease” and treat it accordingly. Is
this the most beneficial way to think about the opioid crisis? What
other conceptual approaches have been put forth?

Pack:
I am certainly not the first to frame it as such. In fact, I’m not
sure who said it first, but I think framing it as a chronic relapsing
disease, such as diabetes, helps to frame opioid use disorder as a
medical problem, with all the inherent physical complexities of a
medical problem, rather than a moral failing or a behavioral problem.
The analogy is particularly apt because type-2 diabetes can be
controlled by diet and exercise in some while others may need insulin
for life. Yet we should not and would not judge people for having
type 2 diabetes and we certainly would not restrict their access to
insulin. We would also endorse social support, cooking classes, other
tertiary prevention opportunities for them. Stigma about mental
illness and substance use disorder prevents us from being so objective
about overdose and even suicide.

EM:
Do we know enough to control this epidemic or is there a scientific or
technical breakthrough that is needed to effectively end the epidemic?

Pack: Much is made of
personalized medicine and the potential for an addiction vaccine. I
support the type of science that is leading to such breakthroughs.
While I am hopeful for the utility of such amazing tools, I know that
they are many years away from being applicable in my community, state
and region. Hence, our team has been focused on identifying the tools
that we already know to be effective, and we’re systematically trying
to implement them in multiple different places, to have the greatest
effect.

We are presently doing original scientific work on
communication between prescribers, dispensers and patients with the
aim of creating interventions to improve accurate risk and
help-seeking communication between each part of the triad. This work
is being led by my colleague Nick Hagemeier, Associate
Professor of Pharmacy Practice and our Center Research Director, and
my senior doctoral student (who just defended her dissertation!)
Stephanie Mathis. Most of the rest of our work is guided by
principles of dissemination and implementation science, or the science
of getting people to use evidence-based tools that we already know are
effective.

EM:
What key interventions exist to counter this epidemic?

Pack:
The epidemic of opioid use disorder is fundamentally interprofessional
in its origin. Hence, solutions to the problem should also be
interprofessional. No one entity is responsible for the epidemic and
efforts to address it need to include all stakeholders. In 2012 we
established the ETSU Prescription Drug Abuse/Misuse Working Group, a
volunteer group that meets monthly. The group is intentionally highly
interprofessional and engaged with the community. The group actually
has over 240 people on the email list but between 30-50 people show up
to our meetings each month. Its open to anyone, and we listen to and
discuss all ideas.

EM:
What happens at these meetings?

Pack: We alternate
on-campus and off-campus meetings to learn more about programs in the
community. Of all the things we've done, the Working Group is by far
the one that is most rewarding and the place where the best ideas
originate.

I view it as a very
fertile ground for new ideas and a place where informal connections
can lead to powerful new partnerships. Members are from many
different organizations and sometimes have very different views on a
topic, but what they all have in common is great interest in finding
solutions, high engagement and tremendous expertise. I wish I could
list them all here, because they are such valuable colleagues, but one
person in particular facilitates these relationships with such skill
that I need to mention her by name. Ms. Angie Hagaman is our
NIDA grant project director, our Center Operations Director, a Masters
prepared counselor and part time DrPH student that has tremendous
instincts for relationships and community engagement.

EM:
How does the Working Group think about the opioid situation?

Pack:
To frame our Working Group efforts, we use a conceptual model based on
a simplified “life course” or “continuum” of addiction to demonstrate
the complexity of the problem and to highlight the fact that there are
many evidence-based interventions that can be implemented at different
points along the continuum. The figure is provided below. By focusing
on the continuum of addiction, it is possible for both university and
community partners, who
might normally only work at different points along the continuum, to
coordinate and collaborate towards the common goal of having a
measurable impact on the problem in the region.

EM: In talking about the
complexity of the crisis, you have said that different groups are
seeing only one part of one elephant in what is actually a herd of
elephants!

What more holistic approach do you see to bending the
curve downward?

Pack:
Heretofore, public health efforts to address the problem have been
fragmented, or focused on only one or two of the interventions on the
continuum. For example, just this week, we learned of a
well-resourced team that met for several days to plan
healthcare-focused solutions to the problem centered around the
prescribing of pain medication. I feel like that was truly missing
the point. That will control some of the supply, but the healthcare
industry has multiple points of concern all along the continuum.

As another example, national level efforts
to educate and train many stakeholders about naloxone have been a
recent focus of the public health systems in many states. While our
Center is also devoted to naloxone distribution, and Dr. Sarah
Melton, Center-affiliated Professor of Pharmacy Practice in our
Gatton College of Pharmacy, worked with our partners to create a
training programs for naloxone administration that have been completed
by more than 38,000 people, it is an unfortunate reality that naloxone
alone will not be the answer to the problem. In fact, though
essential, a focus on naloxone to reverse overdose should be viewed as
a loud and clanging alarm of how urgently primary and secondary
prevention efforts should be brought to bear against the problem.
That's what I mean when I say that this is like a large group of
people with blindfolds on describing an elephant. It's a well knownanalogy. You describe the part of
the elephant that is in front of you. I have also said it is more
like a herd of elephants because there are so many different
perspectives on the right thing to do at different points along the
continuum.

All of the interventions listed along the continuum
have the potential to be scaled up, implemented with high fidelity and
evaluated for local performance. Many even have different points of
intervention at each level of the social-ecological framework. For
example, a primary prevention program for school children may have
modules for the child and also a parent component, a school level
plan, a system level plan and perhaps even a community information
component.

With respect to the figure shared above, ultimately,
the effectiveness of each intervention is interdependent with the
scale of implementation of each of the others. We can’t focus on just
one point along the continuum. We must have a concerted effort at all
points across the social-ecological framework as they target
individuals, families, healthcare initiatives, communities and systems
that all play a role in the epidemic.

EM:
The President stated it will take many years and even decades to
address this scourge in our society. Given that we are in an emergency
situation, is there a reasonable prospect that we can achieve a
significant decrease in deaths more quickly? What would have to happen
to rapidly achieve this desired outcome?

Pack:
One thing that must happen quickly is to create high quality access to
care for everyone that needs it. And we need to reduce payment and
waitlist barriers for people to get engaged in treatment. Payers,
such as Medicaid and insurance providers would be smart to scale up
the treatment side of this as quickly as possible, because the problem
will be even bigger the longer they wait.

EM:
What are the main obstacles to a rapid and effective end to the
epidemic?

Pack:
Stigma and denial. And the drug cartels trafficking in heroin and
fentanyl.

EM:
Unlike other public health problems such as lack of physical
activity, you mentioned that there is a layer of physical dependence
that underlies the drug addiction problem and consequently a deficit
in volitional control that impedes safer and healthier behaviors. In
that way this problem may be similar to sexual risk behavior. Can you
expand a bit further on why this opioid crisis is different from other
public health problems.

Pack:
I mention this because I think many people misunderstand substance use
disorder to be a moral failing and just evidence of bad character, and
that if someone suffering from opioid use disorder just really wanted
to, they could get better. In fact, many of the theories that we
learn about in our public health training are based on a rational
decision making process, that behavior can be changed if we just value
health more than the reward that we get from some risk behavior, or
that behavior is influenced in
a predictable fashion when considering social influences and peer
norms. That is simply not true when you are talking about opioid use
disorder. Habitual use of opioids results in a physical craving for
the drug, when the body is in withdrawal from opioids, that can
overwhelm even the best predictors and models for behavior change.

EM:
What single underused intervention or interventions might we employ
now to ameliorate the epidemic?

I truly wish there was a single intervention that was
that effective for the problem. But there is not.

Pack:
If you were named the Opioid Czar and given $100 million dollars to
control this epidemic, how would you invest it to produce the best
results? Is there agreement among the professionals in your field
about how to invest this money?

I was recently asked this question at a national
meeting. My response reflected the answer I gave above, which is to
accept the complexity of the problem and implement, with high
fidelity, the interventions all along the continuum that have the
greatest potential for return on investment. But on further
reflection, a $100 million investment would represent a unique
opportunity to create a sustainable infrastructure for clinical
treatment that would produce revenues for re-investment into other
primary, secondary and tertiary prevention strategies that I outlined
above. It would create a flywheel effect, to adapt an idea from
Jim Collins’Good to Great. If done carefully, leveraging
partnerships with health systems, mental health care organizations and
networks of community coalitions, that scale of investment would be
transformative for our region and several others. It would require the
establishment of public-private partnerships with much greater
creativity and flexibility than we have seen to this point. I would
use it to establish non-profit, but revenue-generating medical,
pharmaceutical and other treatment entities that would then reinvest
most revenue, above costs, into other non-revenue generating
activities.

For example, health systems with a focus on population
health metrics could establish non-profit medication assisted
treatment clinics, non-profit methadone clinics, and non-profit
pharmacies that could all leverage revenues into programs that are
generally non-revenue generating, such as, but not limited to, school
based primary prevention, harm reduction outreach, clinical education,
naloxone distribution and drug courts. Most of the latter are
typically funded by grants which are usually time limited, limited in
scope and simply not sustainable. In the model I describe, as the
problem shrinks in magnitude, the available revenues would also
shrink. As it grows, revenue for prevention would also grow. Our
Center has entered into such a partnership with our regional health
system, Mountain States Health Alliance, and our regional mental
healthcare system, FrontierHealth and we have opened a non-profit
treatment center wherein revenues will support prevention, outreach,
research and evaluation efforts of our ETSU Center for Prescription
Drug Abuse Prevention and Treatment. It is brand new, having just
opened in late September, but our goal is to deliver state of the art
care to our region, and to reinvest any revenues back into the same
community for population health improvement, evaluation of those
programs and research.

However, if I was actually named the Opioid Czar the
first thing I would do would be to use that massive power to step down
and replace myself with my colleague Stephen Loyd, MD, a true
hero both for the tireless and creative work he is doing every day as
the Medical Director for the Tennessee Department of Mental Health and
Substance Abuse Services, but also for the life of purpose and impact
that he is living while in long-standing recovery from this very
problem.

EM: What do you think our
epidemiologist readers can do to help address this opioid crisis? Is
there a role for them to assume easily and readily at work or in their
communities?

Pack:
This is a great question. Epidemiologists have a tremendous role to
play in the epidemic. A couple of epidemiology highlights, if you
will, are the role that epidemiologists played in halting the spread
of HIV in the rural Indiana countryside in 2015. If your readers
don't know, which is unlikely, Scott County Indiana had an HIV spike
around 2014-2016 where around 200 new cases of HIV were found that
were mostly attributable to sharing needles for injection of opioids.
Some needles were used dozens of times a day and shared between
multiple people. The CDC acted quickly and mitigated the threat. They
did so with great epidemiologists using tried and true shoe-leather
epi methods, network modeling, and the establishment of systematic
harm reduction including one-stop shops for HIV testing, counseling,
safe syringe programs and other preventive services.

Another highlight is the advent and promotion of use of
creative sampling techniques like Respondent Driven Sampling, which
can help investigators learn how to access representative samples of
hidden populations to learn about and assist with their health needs.
Another is the maintenance and reporting of our behavioral and health
statistics that are so important for understanding these complex
issues and how they change over time. I could go on and on. Good
epidemiology is of paramount importance to our work and I’m so
grateful for the work that epidemiologists do.

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